‘Good’ Medicine: Ethics and Pediatric Critical Care. In: Tibboel D, van der Voort E, editors. Intensive Care in Childhood. Berlin: Springer Berlin Heidelberg; 1996. pp. 491-503. [DOI: 10.1007/978-3-642-80227-0_40]

Decision Making and End-of-Life Care in Critically Ill Children

Objectives

1) To comment on the medical literature on decision making regarding end-of-life therapy, 2) to analyze the data on disagreement about such therapy, including palliative care, and withholding and withdrawal practices for critically ill children in the pediatric intensive care unit (PICU), and 3) to make some general recommendations.

Data Sources and Study Selection

All papers published in peer-reviewed journals, and all chapters on end-of-life therapy, or on conflict between parents and caregivers about end-of-life decisions in the PICU were retrieved.

Results

We found three case series, three systematic descriptive studies, two qualitative studies, four surveys, and many legal opinions, editorials, reviews, guidelines, and book chapters. The main determinants of end-of-life decisions are the child's age, premorbid cognitive condition and functional status, pain or discomfort, probability of survival, and quality of life. Risk factors in persistent conflict between parents and caregivers about end-of-life care include a grave underlying condition or an unexpected and severe event.

Conclusion

Making decisions about end-of-life care is a frequent event in the PICU. Children may need both intensive care and palliative care concurrently at different stages of their illness. Disagreements are more likely to be resolved if the root cause of the conflict is better understood.

The moral experience of parents regarding life-support decisions for their critically-ill children: a preliminary study in France

The common paediatric critical care practice in France is for physicians (rather than parents) to maintain the ultimate responsibility for lifesupport decisions in children. Some French literature asserts that it is inappropriate for parents to bear such responsibilities because they do not have the required knowledge and should be protected from feeling culpable for such decisions. The aim of this grounded theory preliminary study was to examine the moral experience of parents of critically-ill children that required life-support decisions in France. A convenience purposive sample of seven parents was recruited in Paris. Five principal themes emerged as significant from these interviews: (1) a need for more information; (2) physicians should be responsible for life-support decisions; (3) the child's concerns and wishes need to be better heard; (4) maternal guilt; and (5) physicians require better training in parent communication. These findings raise important issues for clinical practice and further research in France.

The utility of futility: the construction of bioethical problems

The aim of this article is to analyse the contemporary 'futility discourse' from a constructivist perspective. I will argue that bioethics discourse typically disregards the context from which controversies emerge and the processes that inform and constrain such discourse. Constructivists have argued that scientific knowledge is expressive of the dominant paradigm within which a scientific community is working. I will outline an analysis of 'medical futility' as a construction of biomedical and bioethical communities (and their respective paradigms). I will trace the emergence and utilization of futility in the literature. My analysis of the context (i.e. the historical circumstances, the particular actors involved) within which the futility discourse emerged suggests that medical futility was constructed, in part, as a means of enhancing physician domination of a context wherein medical authority was threatened. The actors in this debate express widely divergent frameworks of 'the good', arguing from distinctive representations of moral agency. At times, this controversy has been argued from incommensurate moral horizons wherein the discussants debate incomparable problems. This discussion is related to a study of the 'practice' of futility in the clinical context. Further studies on the construction of bioethical problems are a necessary condition for supporting the truth claims of bioethical arguments.